Using Estrace Cream Alone with an Intact Uterus is NOT Safe
You need to add a progestogen to your estrogen therapy immediately because unopposed estrogen significantly increases your risk of endometrial hyperplasia and cancer. 1, 2
Why This Matters
The FDA explicitly warns that unopposed estrogens increase the risk of endometrial cancer in women with a uterus, and this applies to both systemic and topical estrogen formulations including vaginal creams. 2 While vaginal estrogen may have lower systemic absorption than oral forms, the risk of endometrial stimulation still exists and requires progestogen protection. 2
What You Need to Do
Add a progestogen to protect your endometrium. The addition of progestogen is mandatory in women with intact uterus and reduces the risk of endometrial hyperplasia and cancer by approximately 90%. 1
Progestogen Options (in order of preference):
Micronized progesterone - This is the optimal choice as it provides endometrial protection without increasing breast cancer risk for up to 5 years of use 1, 3
Medroxyprogesterone acetate - Effective for endometrial protection but may have less favorable breast effects 1
Levonorgestrel-releasing intrauterine system - Another option that provides local endometrial protection 1
Dosing Regimens:
Cyclic (sequential) regimen: 2
- Micronized progesterone 200 mg daily for 12-14 days per month
- Medroxyprogesterone acetate 10 mg daily for 12-14 days per month
Continuous regimen: 2
- Micronized progesterone requires higher doses
- Medroxyprogesterone acetate 2.5 mg daily
- Norethisterone 1 mg daily minimum
The Evidence is Clear
Multiple guidelines confirm that progestogen protection is non-negotiable. The American College of Obstetricians and Gynecologists states that if the uterus has not been removed, the addition of progesterone to estrogen is mandatory to prevent endometrial hyperplasia and cancer. 2 This applies even to low-dose vaginal estrogen preparations. 2
Unopposed estrogen therapy is associated with dose-related endometrial stimulation and significantly increased risk of both hyperplasia and adenocarcinoma. 4, 5 Adding appropriate dose and duration of progestogen lowers this risk to the level found in never-users of estrogen therapy. 5
Critical Warning Signs
Report immediately to your provider if you experience: 2
- Any unusual vaginal bleeding
- Vaginal discharge
- Spotting between periods
Common Pitfall to Avoid
The most dangerous misconception is that vaginal estrogen is "too low dose" to need progestogen protection. This is false - using unopposed estrogen in women with an intact uterus poses a risk of endometrial hyperplasia and cancer regardless of the route of administration. 2
Next Steps
Contact your provider now to discuss adding a progestogen to your regimen. Do not continue using Estrace cream alone. The combination of estrogen plus progestogen will maintain the benefits you're getting from the vaginal estrogen while protecting your endometrium. 1, 5